- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,445.44 / $8,511.38
| Facility | | $1,318.26 | $1,445.44 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $3,019.95
| Professional | | $1,318.26 | $1,548.82 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,235.94 / $3,801.89
| Professional | | $2,630.27 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,630.27 / $4,073.80
| Professional | | $1,548.82 | $2,630.27 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $2,951.21
| Facility | | $1,445.44 | $2,041.74 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $10,715.19
| Professional | | $1,348.96 | $2,187.76 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,819.70 / $2,041.74
| Facility | | $676.08 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,949.84 / $3,162.28
| Professional | | $1,318.26 | $1,949.84 | $3,162.28 |